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Section 1
A 59-year-old woman had 2 months of progressive confusion, urinary incontinence, impaired cognition and gait difficulty. She had a 20-year history of schizophrenia, and at the time of presentation, she was dependent for all activities of daily living. She had taken olanzapine, risperidone and duloxetine for several years with no recent dose changes.
On examination, she was mute with symmetrical cogwheel rigidity with mild bradykinesia, axial rigidity, a broad-based unsteady gait and tending to fall backwards. She had no tremor, and no pyramidal, sensory or cerebellar signs. Funduscopy was normal. She was mildly pyrexic (38°C), with intermittently tachycardic and tachypnoeic, and elevated blood pressure.
Initial investigations included normal full blood count, and normal inflammatory markers including procalcitonin and thyroid function. Serum calcium and creatine kinase were mildly elevated. There was evidence of acute kidney injury due to dehydration, which resolved with intravenous fluids. CT scan of head and MR scan of brain with contrast showed prominent ventricles and narrowed callosum angles (figure 1A, B). MR scan of spine was normal. Electroencephalogram was normal with no features of encephalopathy or seizure activity.
(A, B) MR scan of brain showing dilatation of the lateral ventricles, with subcortical and deep white matter hyperintense lesions, likely small vessel disease. (C) MR scan of chest showing enlarged bulky mediastinal lymph nodes including right paratracheal and prevascular nodes (red arrow) and right axillary lymph nodes (yellow arrow). (D) MR scan of abdomen showing enlarged and bulky bilateral adrenal nodules the largest in the left adrenal (yellow arrows).
Question for consideration
What is the most likely differential diagnosis?
Section 2
Olanzapine and risperidone are second generation antipsychotic medications that can cause an extrapyramidal syndrome, which may explain her rigidity, bradykinesia and gait difficulty. However, she had taken these medications for several years without recent dose changes and so they were unlikely to …
Footnotes
Contributors TH, TA, NL, MS, LN and SW collected data, drafted the manuscript, involved in caring of the patient, corrected the manuscript. All authors approved the manuscript.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Not commissioned; externally reviewed by Neil Scolding, Bristol, UK.
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